Revolution in Treating Infertile Men Turns Hopelessness to Parenthood

By GINA KOLATA

Published: July 19, 1995

ADVANCES in treating male infertility have made it possible for virtually any man who makes even the tiniest amount of sperm to become a father. Even men who have no sperm at all or only dead sperm in their ejaculate or men whose sperm cannot swim or cannot penetrate an egg may be helped.

The most recent discovery builds on the finding that men who have no viable sperm in their semen often have at least a small number in their testes. These sperm are unable to fertilize eggs on their own because they have not undergone maturation and biochemical changes that occur when sperm are transported from the testes through the epididymis, a coiled tube where sperm are stored. They are barely moving because motility also develops during the passage through the epididymis. But they can still fertilize an egg when they are directly injected into it.

The problem has been getting those sperm out of the testes. That required opening up the testes in an operation that cost $10,000 or more, was painful, took place in a hospital and required a month or more of recuperation.

Now, researchers have found a much easier way to extract sperm: by aspirating them through a thin needle in a $1,000 procedure simple enough to be done in a doctor's office.

The change in the prospects for infertile men is little short of amazing, investigators say.

Dr. Richard J. Sherins, the developer of the new fine needle aspiration technique, said it "has completely revolutionized our approach to patients with these problems." Dr. Sherins is the director of the male infertility program at the Genetics and IVF Institute in Fairfax, Va.

So far, he and his colleagues at the institute have used the method on nine men, obtained sperm from all of them, used the sperm to fertilize eggs and achieved four pregnancies. In the case of two of the couples, the doctors do not yet know the outcome of the procedure because the fertilized eggs were implanted in the women so recently that it is too soon to know if the women are pregnant.

Seven of the nine men had normal sperm production but had blockages that prevented sperm from leaving their testes. Two not only had blockages but also were not making many sperm. Their testes had atrophied to less than half the normal size. And one man was unable to ejaculate.

The method is "a huge leap forward," said Dr. Arnold Belker, a urologist at the University of Louisville School of Medicine. But, he cautioned, "There's a strong caveat and that is the ability of patients to afford the advanced reproductive technologies."

Even though fine needle aspiration is not terribly expensive, it is used with in vitro fertilization and the direct injection of sperm into eggs, procedures with very high costs. "You're talking about $9,000 to $14,000 per attempt," Dr. Belke said.

Many insurance companies will not pay, and Dr. Belker said that patients often said they could not afford the therapy.

Nonetheless, the advances in treating male infertility have revolutionized the field in recent years. Researchers used to think that male infertility was all but unsolvable. Sperm production is a complex process that takes three months of maturation and chemical modifications. There were so many places where things could go wrong that it seemed almost impossible to find and fix them. It is so difficult for sperm to come through the process and still be viable that even in a normal fertile man, just 15 percent of the 100 to 300 million sperm produced in an ejaculate are actually capable of fertilizing an egg.

Until recently, most advances in infertility involved treatments for women. Researchers focused on ways to get women to produce eggs and on fertilizing the eggs in the laboratory, creating the lucrative business of in vitro fertilization. Yet problems with sperm loomed large at infertility clinics. An estimated one of every five American couples are infertile and 40 percent of them are unable to have a baby because of a problem with the man's sperm. In 20 percent of infertile couples, both the man and the woman have reproductive difficulties and in the remaining 40 percent the man is fully fertile but the woman is not.

The first breakthrough in treating men occurred two years ago, when researchers discovered that it did not matter whether sperm could swim vigorously to reach an egg. Nor did it matter if the sperm could even enter an egg, dissolving the egg's outer layer and burrowing in. All that mattered was that the sperm, however feeble, were alive. And if they were alive, they could be injected directly into an egg, where they could often fertilize it.

This technique, called intracytoplasmic single-sperm injection, or ICSI, suddenly made previous research, on how to identify viable sperm and how to enhance sperm production, less important. It stripped fertilization down to the basics: just getting the sperm's genes into an egg.

The method was so successful that despite its cost of more than $10,000 per pregnancy attempt, it has already resulted in a diminishing market for sperm donors both in the United States and Europe, said Dr. Joseph Schulman, director of the Genetics and IVF Institute.